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Application Form

THIS FORM DOES NOT GUARANTEE ADMISSION.

Name

Kindly read the information here before completing this form

Child's Details:

Surname *

First Name *

Other Name *

Sex *

Male Female

Date of Birth *

Class *

State of Origin *

Religion *

Denomination *

Name of Previous School *

Parent / Guardian Details:

Title *

Name of Parent/Guardian *

Father's Nationality *

Father's Occupation *

Father's Phone Number *

Father's Alternate Number

Father's Email Address

Mother's Nationality *

Mother's Occupation *

Mother's Phone Number *

Mother's Alternate Number

Mother's Email Address

Full Residential Address in Nigeria *

Health Record:

Has he/she suffered from any of the following ILLNESSES? Please tick and include dates.

Illnesses

Whooping Cough Rubella Typhoid Measles

Has he / she been admitted in the hospital for any illness? If yes, state year of admission, kind of .

illness and duration of admission.

Are there any developmental (health matters or physical) disabilities relating to your child which the authority of the school should know about? If yes, provide details *

Respiratory infection? *

Yes No

Eye problem? *

Yes No

Ear, nose or throat problem? *

Yes No

Any other infirmity or allergy? *

Yes No

Why do you choose to enrol your child/children in our School? *

Declaration *

I certify that I am the person with parental responsibility for the child named above and that the information given is true to the best of my knowledge and belief. I understand that any false or deliberately misleading information given on this form and/or supporting information may render this application invalid, or lead to the offer of a place being withdrawn.

Information Summary

Address

Plot NS 31416, Kurapee Road Karu,961104, Karshi
Abuja, Nigeria.

(234) 7030485063, (234) 8036373346
info@adue.org

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